A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.
Which of the following statements by the client should indicate to the nurse that the medication is effective?
"My voice is no longer hoarse.”
"I am feeling more alert.”
"I don't have a headache anymore.”
"My appetite is increased.”
The Correct Answer is A
Choice A rationale:
Hoarseness of voice can be a symptom of an allergic reaction, indicating swelling and inflammation in the throat. If the client’s voice is no longer hoarse after taking diphenhydramine, it suggests that the medication has been effective in reducing this symptom.
Choice B rationale:
Diphenhydramine is an antihistamine and can often cause drowsiness as a side effect. Therefore, feeling more alert would not typically indicate that the medication has been effective.
Choice C rationale:
While headaches can sometimes be associated with allergic reactions, they are not a primary symptom that diphenhydramine targets. Therefore, absence of a headache does not necessarily indicate effectiveness of the medication.
Choice D rationale:
Increased appetite is not typically associated with the effectiveness of diphenhydramine in treating allergic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.
Choice B rationale:
Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.
Choice C rationale:
Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.
Choice D rationale:
Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.
Correct Answer is B
Explanation
Choice A rationale:
Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.
Choice B rationale:
The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.
Choice C rationale:
Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.
Choice D rationale:
Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.
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